CARES of Washington: Online Program Application Form

<%@LANGUAGE="JAVASCRIPT" CODEPAGE="1252"%> CARES of Washington: Online Program Application Form


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Online Program Application Form
Please fill out the following form to the best of your ability. We are just looking for basic information on this form. When finished hit the submit button, and someone will contact you within the next couple of days. Application Criteria: Any of the following
Disabled and a dislocated worker; have or received SSI or SSDI; have been a claimant with Labor and Industries or Workers Compensation; have or may have a Learning Disability;	have received services from Vocational Rehabilitation services including DVR or DSB; have received drug and alcohol treatment; have or had a stroke, HIV, mental disability, or any other form of physical or mental disorder.

Online Program Application Form

Please fill out the following form to the best of your ability. We are just looking for basic information on this form. When finished hit the submit button, and someone will contact you within the next couple of days.

Application Criteria: Any of the following

Disabled and a dislocated worker;
have or received SSI or SSDI;
have been a claimant with Labor and Industries or Workers Compensation;
have or may have a Learning Disability;

have received services from Vocational Rehabilitation services including DVR or DSB;
have received drug and alcohol treatment;
have or had a stroke, HIV, mental disability, or any other form of physical or mental disorder.

Applicant / Participant's Name:
Street Address:
City:
State:
Zip Code:
Home Phone:
Other Phone:
Date Of Birth:
Age:
Sex: [M/F]
Marital Status:
Minority Group:
How does your disability affect your ability to work?:
Who referred you to CARES of Washington?:
Have you been a participant of any State Vocational Rehabilitation or program?: [Y/N]
If So please supply counselor's name and phone number:
According to your State's Vocational Rehabilitation agency standards, is your disability categorized as significantly disabled?: [Y/N]
Do you or have you ever received SSI or SSDI benefits?: [Y/N]
What was your total earned income last week?: (Do not include SSI, SSDI, or public assistance)
Just before applying to CARES of Washington, how long were you unemployed?:
Work History: [ Copy and paste your work history in this section ]
Have you even been in a union?: [Y/N]
If so, what union? - Local#:
Education: [ Copy and paste your education background in here ]
Primary vocational objective:
Other areas of vocational interest:
Please list any special skills and/or equipment you can operate:
Minimum salary requirement:
Please specify what hours you are willing to work: [ F/T, P/T, PERM, TEMP ]
Transportation available: [ bus/auto ]
Any geographical work site preferences?:

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CARES - Center For Administering Rehabilitation and Employment Services
of Washington
1833 N 105th Street, Suite 201
Seattle, WA 98133
(206) 938-1253

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